In the monthly "Ethical Inquiry" series, we examine ethical questions, highlighting a broad array of opinion from journalism, academia, and advocacy organizations. Our intent is to illuminate and explore the complexity of some of the most vexing ethical questions of our time.

Ethical Inquiry: July 2011

Is There a "Right to Die?" Philosophical, Religious, Legal and Medical Viewpoints

The “right to die” – commonly spoken of in terms of euthanasia or physician assisted suicide – is a principle discussed in religious texts, legal doctrine, and medical journals worldwide.

Recently, the news has been splashed with articles regarding the death of Dr. Jack Kevorkian. Considered a hero by some and a murderer by others, Dr. Kevorkian helped more than 130 people end their lives. His own death (of natural causes) has reminded us of the question, “is there a right to die?”

Does an individual who wishes to die have a right to die? If a terminally ill person, suffering extraordinary pain, wishes to die sooner than he/she would die from the illness, does the patient have a right to die? If a mentally competent and healthy individual, with no traces of depression, believes that he/she has lived a fulfilling life, and feels it is time to die, does this individual have a right to die?

In this "Ethical Inquiry," we will explore the concept of a “right to die” through philosophical, cultural, and medical lenses.

Definitions

Euthanasia

According to Euthanasia.com, a site “… committed to the fundamental belief that the intentional killing of another person is wrong,” euthanasia is the “intentional killing … of a dependent human being for his or her alleged benefit.” Euthanasia is considered “active” if a clear step is taken to end life, whereas the omission of medical attention, for example, qualifies as “passive euthanasia.” The operative word in the definition of euthanasia, however, is “intentional.” If the death was not intentional, it was not euthanasia.

Voluntary, Involuntary, and Nonvoluntary

Similarly, euthanasia can be voluntary, involuntary, or nonvoluntary. Voluntary euthanasia is when the individual asks to die; conversely, involuntary euthanasia is when the individual directly asks not to be euthanized. Nonvoluntary euthanasia, however, is when an individual neither expresses the desire nor provides consent. Voluntary euthanasia is currently most debated, as the other forms of euthanasia are popularly considered murder: the killing of another against his/her will.

Suicide

Voluntary euthanasia is commonly considered suicide. Suicide is when an individual intentionally causes his/her own death. Assisted Suicide is when an individual assists another in intentionally bringing about his/her own death. Physician assisted suicide is defined by MedicineNet.com’s online dictionary as “... the practice of providing a competent patient with a prescription for medication for the patient to use with the primary intention of ending his/her own life.” This is the most commonly debated form of euthanasia.

Cultural Traditions

India

In the tradition of Thalaikoothal, an elderly person was given an oil bath by his or her family members. The individual would then drink coconut water, which would lead to renal failure, fever, and death after several days.

Japan

The elderly or dying individuals in a community were taken to a mountain and left to die in a ceremony called Ubasute.

North America

Some sects of the Inuit tribe are known to have taken their elderly ice fishing, leaving them on ice floes to meet a "natural" death. This was a rare practice, however, and was commonly done only during times of famine. The last known case occurred in 1939.

Serbia

Lapot is the practice of killing parents or elderly family members once they became a financial burden, the individual was brought to the center of town and the community would watch while an axe or stick was used to beat the individual to death. The fairly well known practice is possibly an offshoot of a Roman custom.

These traditions are not examples of voluntary euthanasia, but do represent traditions and practices that end life once a decision has been made about a person’s ability to contribute to society and the quality of that person’s life.

Popular Opinion

According to a 2006 Gallup Poll, as many as 75% of Americans supported a painless end for terminally ill patients. Even when phrased to include the term “suicide” by terminally ill patients, 64% of the population agreed. The notion of a “right to death” for the terminally ill is becoming a culturally accepted norm in the United States.

And that, says Brendan O’Neill, a well-known British social commentator, is the problem. In his May 2010 speech to the South Place Ethical Society, O’Neill states that the acceptance of euthanasia affirms a societal trend of devaluing human life, often equating a life with its economic burden and its environmental impact. Though O’Neill admits he may not be entirely against the notion of an individual getting to choose when he or she dies, codifying this belief into a right is certainly problematic.

To O’Neill, the bureaucracy that would surround such a right would make the decision traumatic and public, whereas the decision to die is an “intensely private decision” intended to alleviate suffering and pain, be it physical, mental, spiritual or otherwise.

Religious Views

Most of the opposition to euthanasia is based in religious tradition. Although as many as 75% of Americans believe that terminally ill patients have a right to die, a 2004 Gallup Poll showed that only around 33% of individuals “who attend religious services weekly … regard euthanasia as morally acceptable.” This stark disparity shows the impact of religious views on personal opinions regarding euthanasia.

The major world religions are all fairly equivalent in their view that the intentional taking of life, be it suicide or euthanasia, is unacceptable. The main religious arguments against euthanasia, as noted by the BBC “Ethics Page” on euthanasia and religion, include:

To Christians, Jews, and Muslims, life is God-given and sacred. Therefore, killing someone or taking active steps to assist someone in death is wrong because it overtakes God’s role.

To Hindus and Buddhists, suicide or euthanasia interrupts the natural cycle of life and death.

The idea that physician assisted suicide would make it a responsibility for someone to kill deems it immoral (as somewhat denoted in American and Dutch laws regarding rights to die).

The 1976 case of Karen Quinlan was the first US court case regarding a right to death. When 22-year-old Quinlan was in a persistent vegetative state after mixing alcohol and drugs, her father made the decision to end life support. The New Jersey Supreme Court ruled that the State’s interest diminished as the potential for life diminished, thus relinquishing authority to make the decision to the family.

This ruling touched upon the crux of the issue. If an individual has the right to refuse treatment, why do they not also hold the right to request treatment? The 1997 case of Vacco v. Quill determined that there is a difference between the refusal of lifesaving treatment and the taking of lethal medication.

The Cruzan case also made clear that in the instance of an incompetent individual, the state has the power of authority. Furthermore, the Court defined the following points as government interests:

the protection of life,

the prevention of suicide,

protection of the ethical integrity of the field of medicine,

the protection of vulnerable groups, and

protection against the slippery slope towards euthanasia.

In order to uphold the ethical integrity of the medical field – as well as the aforementioned interests of the state – the American Medical Association’s approved, modernized version of the Hippocratic Oath includes the statement that “…you will exercise your art solely for the cure of your patients, and will give no drug, perform no operation, for criminal purpose, even if solicited, far less suggest it.”

However, the meaning of “curing” or caring for a patient is problematic: to some that always means survival, for others it could mean ending suffering, even by death.

In order for the law to apply, the following requirements must be met:

The individual must be a resident of the State of Oregon, have a terminal illness, and be within 6 months of death.

The individual must have no mental condition that could impair judgment, as determined by a psychological evaluation.

The individual must make an oral request, followed by a second oral request to be made 15 days later.

A second doctor must confirm the diagnosis.

Two witnesses must be present, one of whom must not be related to the patient nor written into the patient’s will.

The request must be patient-initiated, and anyone who is morally opposed – including doctors, nurses, and pharmacists – can refuse participation.

The law explicitly states that no “lethal injection, mercy killing, or active euthanasia” is permissible. In other words, doctors can merely write prescriptions: they are not allowed to actively assist in death, themselves.

The New England Journal of Medicine article “Experiences of Oregon Nurses and Social Workers with Hospice Patients Who Requested Assistance with Suicide” (2002) reports that the common reasons patients desire physician assisted suicide include: loss of independence, poor current or future quality of life, readiness to die, and desire to control the circumstances of death. The report also noted that – when considering issues of treatment for depressed patients – feelings of hopelessness and feelings of depression should be understood as different indicators.

Is this only for the terminally ill? Even if it is only for the terminally ill, do we risk sending a message about whose lives are worth living? Nora Miller notes in “Death with dignity or criminal act?” that "Many concerned with the rights of disabled people view this law as a step down the infamous "slippery slope" toward euthanasia." Among the reasons cited by people with this concern, is that “If we allow or even encourage the terminally ill to consider ending their lives rather than helping them to cope with their symptoms, we send a message to the disabled community that we consider their lives possibly unbearable, as well.” Miller contends that "This line of thinking glosses over the extreme specificity of Oregon's law, requiring as it does that the patient have mere weeks or months to live, with no hope of continuing any kind of life, much less a 'normal' one. With a horizon of years instead of weeks," she writes, "the disabled clearly have different needs for treatment and acceptance than do the terminally ill."

Are we at risk of legalizing “senicide” – the killing of the elderly?

In his New York Times op-ed “Dr. Kevorkian’s Victims” Ross Douthat asserts that “Once we allow that such a right exists, the arguments for confining it to the dying seem arbitrary at best.” Therefore, do the dying create a disparate moral category, to whom a new set of rules applies?

The law cannot answer these existential questions. Ideally, if something is legal then it is moral; however, that is not necessarily the case.

Humanitarianism, or Crime? The Philosophical and Moral Grounding of the Arguments

In addition to legal and medical tradition, there are a range of philosophical arguments regarding the concepts of “appropriate” and “inappropriate” forms and methods of euthanasia.

As noted in the definitions, there is often an implied moral distinction made between the different types of euthanasia. To be clear, withdrawing a feeding tube from a patient with throat cancer and letting death come as a result is passive euthanasia. Active euthanasia entails the patient making the same decision to die, followed by the administration of an intentional overdose of morphine for a painless death. These voluntary forms of euthanasia are considered by many to be the most ethically sound.

On the other hand, active involuntary euthanasia – intentionally taking steps to end another’s life against his/her express will – is commonly considered the least defensible.

Thus, along with the moral admissibility of voluntary euthanasia, we are left in murky water when it comes to passive involuntary euthanasia and passive nonvoluntary euthanasia: letting someone die by withdrawing life support, despite whatever wishes (or lack thereof) come from the individual.

A leading philosopher on the issue of euthanasia is James Rachels. In the article “Active and Passive Euthanasia,” (New England Journal of Medicine, 1975 - subscription may be required) Rachels makes three main arguments in response to conventional claims regarding the permissibility or impermissibility of euthanasia. He claims:

In response to general notions that passive euthanasia may be acceptable but active euthanasia may not, once the decision is made for an individual’s life to end, active euthanasia is more in line with alleviating suffering – the original intent of either form of euthanasia.

Passive and active euthanasia are either right or wrong for the same reasons.

There is no moral distinction between ‘killing’ and ‘letting die.’ Rachels denotes that “letting die” is not inaction; instead, it is an action taken to not do other actions. Agency, in the case of “letting die,” is therefore still a factor, and there is no moral distinction between the act of letting die and the act of killing – at least in relation to a doctor and medical treatment.

Ultimately, according to Rachels, if one accepts passive euthanasia then he/she would be cruel not to take active steps to end a life quickly and painlessly. Further, if passive euthanasia (letting die) is “… not [the intentional termination of a life], then there would be no point in it;” thus, no moral distinction exists.

Douthat writes that “If participating in a suicide is legally and ethically acceptable, it can’t just be because cancer is brutal and dementia is dehumanizing. It can only be because there’s a right to suicide.” In other words, if we can agree that a patient on his/her deathbed has the right to die with dignity, why does a middle-aged citizen not have the same choice?

Furthermore, the necessity of philosophical arguments for the legitimacy of euthanasia are being questioned since palliative care is improving. Palliative care is end-of-life care aimed at treating physical, mental, and spiritual pain, and it is now possible for many patients to live through their final months free of pain.

Final Thoughts

Despite the ability to choose death – and, since suicide is not illegal in America, this is technically feasible in any state – still only a minority choose death. Furthermore, the individuals that received assistance under the "Death With Dignity Act" in Oregon represent equivalent diversity to the total population who has died: there is no slant towards the poor, those of a racial minority, the uneducated, the disabled, women, or any other marginalized group – at least not yet.

What, if any, risks still exist for the aforementioned vulnerable groups?

Some fear that the more common the acceptance of euthanasia, the more likely it is that a cultural “standard” for life will be developed, possibly putting pressure on individuals not achieving that “standard” – particularly those with disabilities – to end their lives. Is this a valid concern? (Also see: Assisted Suicide: A Disability Perspective," [PDF] a 1997 position paper from the National Council on Disability.)

Is Rachels correct? Once we accept that passive voluntary euthanasia is acceptable, is it logically impossible to conclude that active voluntary euthanasia is any less moral? Is there a difference between “letting die” and “killing”?